Predictors of bloodstream infection associated with permanently implantable venous port in solid cancer patients

Risk Factors for Unplanned Early Implantable Port Catheter Removal in Adult Hematology Cancer Patients Receiving Chemotherapy: A Propensity Score Matching Study

Purpose

Implantable port catheter is a reliable vascular access for chemotherapy infusion in cancer patients. However, patients with hematology malignancies usually present with a myriad of blood cell abnormalities that put them at risk of infection and mechanical problems requiring catheter removal. This study aims to determine the risk factors associated with unplanned (catheter removal other than completion of treatment plan) early (within 90 days of catheter implantation) implantable port catheter removal.

Patients and Methods

A retrospective, propensity score-matched study of 386 patients with hematology malignancies who received implantable venous access ports between January 2015 and December 2022. We conducted a univariate analysis to select the variables for propensity score matching. Patients with unplanned early implantable port catheter removal (early group) were matched 1:1 to patients without unplanned early removal (non-early group).

Results

Univariate analysis demonstrated a statistically significant difference between early and non-early groups for age (p = 0.048), hemoglobin level (p = 0.028), thrombocytopenia (p = 0.025), and PG-SGA (p < 0.001). Thrombocytopenia was the only independent risk factor with a statistically significant difference in Cox proportional hazard analysis, HR 2.823, 95 CI 1.050-7.589, p = 0.040. The median catheter survival for patients with thrombocytopenia was 61 days (95% CI 28.58-93.42) compared to 150 days (95% CI 9.81-290.19) for patients without thrombocytopenia, p = 0.015. Patient survival is not affected by early catheter removal. The median survival for patients in the early group was 28.28 months (95% CI 27.43-29.15) compared to 32.39 months (95% CI 24.11-40.68), for the non-early group, p = 0.709.

Conclusion

Hematology malignancy patients with thrombocytopenia are at high risk for unplanned early port catheter removal without survival difference.

Silver-Mixed Port Reduces Venous Access Port Related Infection Rate Compared to Non-Silver-mixed Port: A Single-center Retrospective Analysis

PURPOSE

Totally implantable venous access ports (TIVAPs) are increasingly used as safe and convenient central venous access devices. However, several TIVAP-related complications occur, with port/catheter infection being most common. Silver-mixed ports have recently been introduced in anticipation of reducing TIVAP infection. This study aimed to investigate the efficacy of this device in reducing port infection by examining groups with and without silver-mixed devices.

MATERIALS AND METHODS

From April 2017 to July 2022, silver-mixed ports (S group) and non-silver-mixed port group (NS group) were reviewed at our institution. The incidence of TIVAP-related infections, patient characteristics, and bacteriological data were evaluated. Univariate and multivariate analyses were used to evaluate risk factors for TIVAP-related infection.

RESULTS

A total of 607 patients (S group, n = 203; NS group, n = 404) were enrolled. The rates of TIVAP-related infection were 3.0% (n = 6) and 7.7% (n = 31) in the S and NS groups, respectively. The incidence of total infection per 1000 catheter-days were 0.114 and 0.214 the S and NS groups, respectively. In the entire group, the rates of infection were 6.1% (n = 37) and the incidence of total infection per 1000 catheter-days was 0.187. Univariate and multivariate analyses revealed a significantly lower TIVAP-related infection rate in S group than NS group (p = 0.0216, odds ratio = 2.88 confidence interval: 1.17-7.08). No gram-negative rods were detected in the S group as port infection.

CONCLUSION

Silver-mixed port may be feasible in preventing port infection.

LEVEL OF EVIDENCE

Level 3, Local non-random sample.

Risk factors and prognostic significance of infection of totally implantable vascular access port in solid tumor patients: A prospective cohort study

OBJECTIVES

Totally implantable venous access ports (TIVAP) are devices mainly used to deliver antineoplastic chemotherapies, of which the insertion may be complicated by TIVAP-related infection (TIVAP-RI). This study aims to provide data on the risk factors for TIVAP-RI and its influence on patient prognosis.

PATIENTS AND METHODS

Prospective observational study including adult patients with solid tumors, in whom a TIVAP was inserted to deliver antineoplastic chemotherapy between January 2018 and October 2019. Factors associated with TIVAP-RI and one-year mortality were determined using multiple logistic regressions.

RESULTS

More than a thousand (1014) patients were included, among whom 48 (4.7%) presented with TIVAP-RI. Gram-positive cocci and Gram-negative bacilli represented 51% and 41% of the pathogens isolated, respectively. Young age (odds ratio [OR] 0.67; 95% Confidence Interval [0.53-0.83] per 10-year increase), WHO performance status ≥ 1 (OR 3.24 [1.52-7.79]), chemotherapy administration in the month before TIVAP placement (OR 2.26 [1.17-4.26]), and radiation therapy of the homolateral chest wall (OR 3.28 [1.51-6.67]) were independently associated with TIVAP-RI occurrence. During the year following TIVAP insertion, 287 (28%) patients died. TIVAP-RI was not associated with one-year mortality (OR 1.56 [0.75-3.19]).

CONCLUSION

TIVAP insertion in adult patients with solid tumors is associated with a low infection rate, which did not influence one-year mortality. In addition to young age and impaired health status, TIVAP insertion in the month following initiation of the antineoplastic chemotherapy and TIVAP insertion in an irradiated area are two newly reported preventable TIVAP-RI risk factors.

Systematic review finds risk of bias and applicability concerns for models predicting central line-associated bloodstream infection

OBJECTIVES

To systematically review the risk of bias and applicability of published prediction models for risk of central line-associated bloodstream infection (CLA-BSI) in hospitalized patients.

STUDY DESIGN AND SETTING

Systematic review of literature in PubMed, Embase, Web of Science Core Collection, and Scopus up to July 10, 2023. Two authors independently appraised risk models using CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) and assessed their risk of bias and applicability using Prediction model Risk Of Bias ASsessment Tool (PROBAST).

RESULTS

Sixteen studies were included, describing 37 models. When studies presented multiple algorithms, we focused on the model that was selected as the best by the study authors. Eventually we appraised 19 models, among which 15 were regression models and four machine learning models. All models were at a high risk of bias, primarily due to inappropriate proxy outcomes, predictors that are unavailable at prediction time in clinical practice, inadequate sample size, negligence of missing data, lack of model validation, and absence of calibration assessment. 18 out of 19 models had a high concern for applicability, one model had unclear concern for applicability due to incomplete reporting.

CONCLUSION

We did not identify a prediction model of potential clinical use. There is a pressing need to develop an applicable model for CLA-BSI.

Pre-Procedure Thrombocytopenia and Leukopenia Association with Risk for Infection in Image-Guided Tunneled Central Venous Catheter Placement

Placement of image-guided tunneled and non-tunneled large-bore central venous catheters (CVCs) are common procedures in interventional radiology. Although leukopenia and/or thrombocytopenia are common at the time of placement, the roles these factors may have in subsequent catheter-related infection have yet to be investigated. A single-institution retrospective review was performed in patients who underwent CVC placement in interventional radiology between 11/2018–6/2019. The electronic medical record was used to obtain demographics, procedure details, pre-placement laboratory values, and the subsequent 90-day follow-up. A total of 178 tunneled and non-tunneled CVCs met inclusion criteria during this time period. White blood cell (WBC) and platelet counts were found to be significant risk factors for subsequent infection. Administration of pre-procedure antibiotics was not found to be a significant factor for subsequent infection (p = 0.075). Leukopenia and thrombocytopenia at the time of CVC placement are both risk factors of line infection for tunneled large-bore CVCs. This should lead to the consideration of using a non-tunneled CVC when clinically feasible, or the delayed placement of these catheters until counts recover.

Postoperative Rather Than Preoperative Neutropenia Is Associated With Early Catheter-related Bloodstream Infections in Newly Diagnosed Pediatric Cancer Patients

BACKGROUND

The relationship of early catheter-related bloodstream infections (CRBSIs) with perioperative neutropenia and antibiotic prophylaxis is not well established. We sought to evaluate perioperative factors associated with early CRBSIs in newly diagnosed pediatric cancer patients, particularly hematologic indices and antibiotic use.

METHODS

We retrospectively reviewed national registry records of newly diagnosed pediatric cancer patients with port-a-caths inserted using standardized perioperative protocols where only antibiotic use was not regulated. Thirty-day postoperative CRBSI incidence was correlated with preoperative factors using logistic regression and with postoperative blood counts using linear trend analysis.

RESULTS

Among 243 patients, 17 CRBSIs (7.0%) occurred at median 14 (range, 8-28) postoperative days. Early CRBSIs were significantly associated with cancer type [acute myeloid leukemia and other leukemias (AML/OLs) vs. solid tumors and lymphomas (STLs): odds ratio (OR), 5.09; P = 0.0036; acute lymphoblastic leukemia vs. STL: OR 0.83; P = 0.0446] but not preoperative antibiotics, absolute neutrophil counts and white blood cell counts. Thirty-day postoperative absolute neutrophil counts and white blood cell trends differed significantly between patients with acute lymphoblastic leukemia and STLs (OR 0.83, P < 0.05) and between AML/OLs and STLs (OR 5.09, P < 0.005), with AML/OL patients having the most protracted neutropenia during this period.

CONCLUSIONS

Contrary to common belief, low preoperative absolute neutrophil counts and lack of preoperative antibiotics were not associated with higher early CRBSI rates. Instead, AML/OL patients, particularly those with prolonged neutropenia during the first 30 postoperative days, were at increased risk. Our findings do not support the use of empirical preoperative antibiotics and instead identify prolonged postoperative neutropenia as a major contributing factor for early CRBSI.

Safety of immediate use of totally implantable venous access ports in adult patients with cancer: a retrospective single-center study

Purpose

Totally implantable venous access ports (TIVAPs) can be used long-term for safe administration of intravenous drugs. TIVAP complications include catheter-related infections, venous thrombosis, extravasation, TIVAP migration, and pain. The relationship between the timing of the first chemotherapy administration after port implantation and complications is controversial. This study aimed to investigate the safety of immediate use of TIVAPs and the associated risk factors for complications.

Methods

Between January 2016 and December 2018, 305 patients (median age, 53 years; 256 women) who underwent TIVAP placement at our institution were included. Chemotherapy was administered within 2 days of implantation. A retrospective analysis of patients' clinical data was performed to investigate catheter days and complications of TIVAPs.

Results

Overall, 305 patients were evaluated over 57,324 catheter days (median, 168 catheter days; interquartile range, 105). The median interval between placement and first use of TIVAPs was 0.98 days. The overall morbidity rate was 2.95%. Nine complications occurred in nine patients, including TIVAP-related infection (4), pain (2), port occlusion (1), thrombosis (1), and scar disunion (1), of which five required port removal (1.64%). The median number of catheter days before complications occurred was 61 (range, 10-457 days; interquartile range, 51). No complications occurred within 7 days of implantation. Body mass index was an independent risk factor for TIVAP-related complications in the Cox proportional hazards model (multivariable analysis: hazard ratio, 1.221; 95% confidence interval, 1.054-1.414; P=0.008).

Conclusion

This study suggests the safe long-term use of TIVAPs following their immediate chemotherapy administration within 2 days of implantation.

Impact of chest subcutaneous fat on the occurrence of central venous port-related infectious complications in cancer patients

Purpose

There is no concrete evidence to support the association between the amount of subcutaneous fat area (SFA) in the central venous port-insertion site (precordium) and port-related complications. We aimed to investigate the relationship between SFA in the midclavicular line and postoperative infectious complications in patients undergoing port-insertion surgery.

Methods

This was a single-institute and historical cohort study of 174 patients who underwent first central venous port implantation surgery for chemotherapy between January 2014 and December 2018. SFA in the midclavicular line was measured using preoperative computed tomography scans. The patients were divided into three groups according to SFA amount tertiles, and we investigated the association of SFA with infectious and all-cause complication events within 1 year.

Results

Within a median follow-up of 306 days, the patients with intermediate SFA had significantly higher infection-free survival than those with low and high SFA (low vs. intermediate vs. high: 80.4% vs. 97.7% vs. 83.4%, respectively, p=0.034). In contrast, there was no significant difference in the overall complication-free survival among the groups (low vs. intermediate vs. high: 80.4% vs. 88.9% vs. 81.8%, respectively, p=0.29). Low SFA was independently associated with high risk of infectious complications (hazard ratio, 9.45; 95% confidence interval, 1.07–83.22, p=0.043).

Conclusion

Low SFA in the midclavicular line was an independent risk factor for infectious complications in the chemotherapy setting. This practical indicator can be useful for optimizing patients’ nutritional status and when considering other types of vascular access to support administration of intravenous chemotherapy.

Use of catheter with 2-methacryloyloxyethyl phosphorylcholine polymer coating is associated with long-term availability of central venous port

Central venous port (CVP) is a widely used totally implantable venous access device. Recognition of risks associated with CVP-related complications is clinically important for safe, reliable, and long-term intravenous access. We therefore investigated factors associated with CVP infection and evulsion, including the device type. A total of 308 consecutive patients with initial CVP implantation between January 2011 and December 2017 were retrospectively reviewed, and the association of clinical features with CVP-related complications were analyzed. Intraoperative and postoperative complications occurred in 11 (3.6%) and 39 (12.7%) patients, respectively. The overall rate of CVP availability at six months was 91.4%. Malignancy and 2-Methacryloyloxyethyl phosphorylcholine (MPC) polymer-coated catheter use were negatively associated with the incidence of CVP infections. Accordingly, malignancy and MPC polymer-coated catheter use were independent predictors for lower CVP evulsion rate (odds ratio, 0.23 and 0.18, respectively). Furthermore, both factors were significantly associated with longer CVP availability (hazard ratio, 0.24 and 0.27, respectively). This retrospective study identified factors associated with CVP-related complications and long-term CVP availability. Notably, MPC polymer-coated catheter use was significantly associated with a lower rate of CVP infection and longer CVP availability, suggesting the preventive effect of MPC coating on CVP infection.

Chemoport-associated Complications and Its Management

Chemoport is being routinely used to administer chemotherapy, blood, blood products, total parenteral nutrition, and also to draw blood for investigations. We started using chemoport in our institute. We use it exclusively to administer chemotherapy. We analyzed our results of chemoport usage and confirm that the rate of complications associated with chemoport usage is at par with the available literature. We also conclude that with regular use, the intra-op and post-op complications will reduce further.

Risk Factors for Early Port Infections in Adult Oncologic Patients

PURPOSE

The purpose of this study was to retrospectively investigate risk factors for chest port (port) infections within 30 days of placement (early port infections) in adult oncologic patients.

MATERIALS AND METHODS

This single-institution, three-center retrospective study identified 1,714 patients (868 males, 846 females; median age 60.0 years old) who underwent port placement between January 2013 and August 2017. All patients received an intravenous antibiotic prior to port placement. The median absolute neutrophil count was 5,260 cells/μL, the median white blood cell (WBC) count was 7,700 cells/μL, and the median serum albumin was 4.00 g/dL at the time of port placement. Double-lumen ports were most commonly implanted (74.85%) more frequently in an outpatient setting (72.69%). Risk factors for early port infections were elucidated using univariate and multivariate proportional subdistribution hazard regression analyses.

RESULTS

A total of 20 patients (1.2%) had early port infections; 15 patients (0.9%) had positive blood cultures. The mean time to infection was 20 days (range, 9-30 days). The port-related 30-day mortality rate was 0.2% (4 of 1,714 patients). Most bloodstream infections were attributed to Staphylococcus spp. (n = 11). In multivariate analysis, hematologic malignancy (hazard ratio [HR], 2.61; 95% confidence interval (CI), 1.15-5.92.; P = .02), hypoalbuminemia (albumin <3.5 g/dL; HR, 3.52; 95% CI: 1.48-8.36; P = .004), leukopenia (WBC <3,500 cells/μL; HR, 3.00; 95% CI: 1.11-8.09; P = .03), and diabetes mellitus (HR, 3.71; 95% CI: 1.57-8.83) remained statistically significant risk factors for early port infection.

CONCLUSIONS

Hematologic malignancy, hypoalbuminemia, leukopenia, and diabetes mellitus at the time of port placement were independent risk factors for early port infections.

The Profile of Microorganisms Responsible for Port-Related Bacteremia in Pediatric Hemato-Oncological Patients

Patients with pediatric cancer face an increased risk of infections. In most cases, these infections are associated with the use of a long-term central venous catheter. This study describes the epidemiology of a port-associated bacteremia as well as a profile of microorganisms responsible for port-associated bloodstream infections (PABSIs) in pediatric patients with cancer treated in a single center. The retrospective analysis included patients with cancer who had implanted a port, hospitalized between 2010 and 2015 at the Department of Pediatric Oncology, Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences. The medical records of patients were reviewed for demographic characteristics, diagnosis, port-related complications, and their management. Data were collected from patients' electronic medical records containing complete information on medical examinations and supplementary tests, diagnosis, timing, and type of port-associated complications. In a study period, 277 ports were inserted to 241 patients. A total of 183 094 catheter days were analyzed. Sixteen patients had more than 1 insertion of a port. The commonest observed complication was PABSI (40.07%) and the incidence density was 0.6 per 1000 port-days. Staphylococcus was the most commonly isolated organisms from patients with PABSI. From all port-associated complications, bloodstream infections and mechanical complications were the most often observed complications. The commonest pathogens responsible for PABSI were coagulase-negative staphylococci. Pathogens resistant to standard antibiotic treatment play an important role in PABSI, with methicillin-resistant Staphylococcus epidermidis being the predominant pathogen. Port-associated bloodstream infections are a common reason for preterm removal of a port.

Incidence of and risk factors for totally implantable vascular access device complications in patients with gastric cancer: A retrospective analysis

Totally implantable vascular access devices (TIVADs) are often used to administer chemotherapy by prolonged intravenous infusion. The objective of the present study was to investigate the incidence of long-term complications and identify risk factors associated with TIVAD placement in patients with gastric cancer. A total of 121 patients with gastric cancer who had undergone 150 TIVAD placement procedures for chemotherapy or supportive care were enrolled in the present retrospective cohort study. A number of risk factors were analyzed, including age, sex, hypertension, diabetes mellitus, history of thrombosis, body mass index, disease stage, and site and purpose of TIVAD. In total, 40 TIVADs (26.7%) developed long-term complications, of which 27 (18.0%) were infections, seven (4.7%) were catheter-related deep vein thrombosis (CR-DVT), and six (4.0%) were obstructions. Chemotherapy was associated with an increased rate of infectious adverse events (odds ratio 2.925; 95% CI, 1.104-7.750; P=0.031) according to the multivariate analysis. CR-DVT occurred more frequently in upper arm ports than in chest wall ports; however, this difference was not statistically significant (7.5 vs. 0.0%; P=0.084) according to the univariable analysis. All CR-DVTs developed in the upper arm sites. Chemotherapy and the upper arm site were associated with long-term complications in patients with TIVAD. However, further studies are needed to confirm the findings of the present study and to determine the reasons for the high incidence of long-term complications in these patients.

Epidemiology of Infectious and Noninfectious Catheter Complications in Patients Receiving Home Parenteral Nutrition: A Systematic Review and Meta-Analysis

Patients receiving parenteral nutrition (PN) as their primary source of nutrition are at high risk for both infectious and noninfectious catheter complications (catheter-related infections, catheter occlusion, and venous thrombosis). The aim of this review was to synthesize and evaluate what is known about catheter complications and prevention strategies in the PN population. Three electronic databases (Medline, Embase, and CINAHL) were screened for studies published between January 2012 and February 2019 regarding infectious and noninfectious catheter complications in patients receiving PN. Rates of infectious and noninfectious catheter complications, prevalence of causative pathogens, potential risk factors, and prevention strategies via the use of antimicrobial lock therapy (ALT) were assessed. Fifty-three catheter complication studies and 12 ALT studies were included. Studies were grouped by definition of complication: catheter-related bloodstream infections (CRBSI) or central line-associated bloodstream infections (CLABSI). Random effects summary rates per 1000 catheter days were 0.85 CRBSI episodes (95% CI 0.27-2.64) and 1.65 CLABSI episodes (95% CI 1.09-2.48). Use of taurolidine or ethanol ALT was efficacious in reducing infectious catheter complications; however, several studies had concerns for adverse mechanical complications. Potential risk factors for catheter complications were highly varied and often contradictory between studies. The rates of catheter complications were higher among catheterized patients receiving PN compared with nationally reported rates of complications in all catheterized patients. Risk factors for catheter complications need to be better understood for targeted prophylactic use of ALT. Future studies are warranted; however, they should be conducted using more standardized definitions and criteria.

Right- versus Left-Sided Chest Ports in Oncologic Patients with a History of Right-Sided Port Removal: Are There Any Differences in the Complication Rates?

PURPOSE

To compare chest port (port)-related complication rates between right- and left-sided ports placed in adult oncologic patients with a history of right-sided port removal.

MATERIALS AND METHODS

A retrospective chart review identified 90 adult oncologic patients with a history of right-sided port removal. Of these, 60 patients had a second port placed on the right side (right-side group), while 30 patients had a second port placed on the left side (left-side group). Median time between first port removal and second port placement was 217 days (range, 0-3808 days). Port-related complications included infection (port-site and/or bloodstream), mechanical, thrombotic, and port-site skin complications. Complication rates between groups were compared. Proportional subdistribution hazard regression (PSHREG) was conducted to determine if laterality of the second port is an independent risk factor for port-related complications.

RESULTS

The cumulative follow-up period was 34,748 catheter-days (median, 233; range, 9-2162 days). Eleven patients (18.3%) in the right-side group and 2 patients (6.7%) in the left-side group had port-related complications (P = .21), accounting for complication rates of 0.5 and 0.2/1000 catheter-days (P = .24), respectively. No statistical difference was found in the incidence of infection (9/60 vs 1/30, P = .16), mechanical (0/60 vs. 1/30, P = .33), thrombotic (1/60 vs 0/30, P = 1.0), and skin-related (1/60 vs 0/30, P = 1.0) complications between groups. In multivariate PSHREG, laterality of the second port (hazard ratio = 3.09, 95% confidence interval = 0.81-11.76, P = .10) was not a significant risk factor for port-related complications.

CONCLUSIONS

In adult oncologic patients with a history of right-sided port removal, no significant differences in port-related complication rates were observed between right- and left-sided second ports.

Association between Periprocedural Neutropenia and Early Infection-related Chest Port Removal

Background Patients who require long-term central venous access can present for port placement with depressed immune function as a result of their treatment or disease process. At present, there is no consensus regarding whether neutropenia at the time of port placement confers a higher risk for early infection-related port removal. Purpose To compare the incidence of early infection-related chest port removal in adults when placed in neutropenic versus nonneutropenic patient groups. Materials and Methods This retrospective cohort study examined 2580 port placements in 1081 men (41.9%) and 1499 women (58.1%) at a single tertiary medical center between June 2007 and July 2017. Mean patient age ± standard deviation was 56 years ± 14 (range, 18-91 years). The electronic medical record was used to identify neutropenia (absolute neutrophil count <1500 cells/mm³) at the time of port placement and incidence of infection-related port removal. Electronic medical record follow-up was conducted for 30 days following port placement. End points were infection-related port removal or death related to port infection within 30 days. Statistical analysis compared the neutropenic (n = 159) and nonneutropenic (n = 2421) patient groups by using a χ² test for categorical data and a Student t test for continuous variables, with a Fisher exact test to compare incidence of port removal and death related to port infection. Results Ports placed in patients with neutropenia had an infection-related removal rate of 3.8% (six of 159) versus 0.91% (22 of 2421) in patients without neutropenia (P = .003). Patients with neutropenia had a port infection-related death rate of 0.63% (one of 159) versus 0.12% (three of 2421) for patients without neutropenia (P = .22). Conclusion Neutropenia in adults at the time of implantable subcutaneous chest port placement was associated with a higher risk for early infection-related port removal. There was no difference in the incidence of death related to port infection in neutropenic or nonneutropenic populations. © RSNA, 2019 See also the editorial by Johnson in this issue.

Neutropenia at the time of subcutaneous port insertion may not be a risk factor for early infectious complications in pediatric oncology patients

BACKGROUND

The risk of infection associated with subcutaneous port (SQP) placement in patients with neutropenia remains unclear. We reviewed the rate of early infectious complications (<30 days) following SQP placement in pediatric oncology patients with or without neutropenia [absolute neutrophil count (ANC) <500/mm³].

METHODS

Baseline characteristics and infectious complications were compared between groups using univariate and multivariate analyses.

RESULTS

A total of 614 SQP were placed in 542 patients. Compared to nonneutropenic patients, those with neutropenia were more likely to have leukemia (n = 74, 94% vs n = 268, 50%), preoperative fever (n = 17, 22% vs n = 25, 5%), recent documented infection (n = 15, 19% vs n = 47, 9%), and were younger (81 vs 109 months) (p values <0.01). After adjusting for fever and underlying-disease, there was a nonsignificant association between neutropenia and early postoperative infection (OR 2.42, 95% CI 0.82-7.18, p = 0.11). Only preoperative fever was a predictor of infection (OR 6.09, 95% CI 2.08-17.81, p = 0.001).

CONCLUSION

SQP placement appears safe in most neutropenic patients.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Role of Lock Therapy for Long-Term Catheter-Related Infections by Multidrug-Resistant Bacteria

The management of long-term central venous catheter (LTCVC) infections by multidrug-resistant (MDR) bacteria in cancer patient is a challenge. The objectives of this study were to analyze outcomes in cancer patients with LTCVC-associated infection, identify risks for unfavorable outcomes, and determine the impact of MDR bacteria and antibiotic lock therapy (ALT) in managing such infections. We evaluated all LTCVC-associated infections treated between January 2009 and December 2016. Infections were reported in accordance with international guidelines for catheter-related infections. The outcome measures were 30-day mortality and treatment failure. We analyzed risk factors by Cox forward-stepwise regression. We identified 296 LTCVC-associated infections; 212 (71.6%) were classified as bloodstream infections (BSIs). The most common agent was Staphylococcus aureus Forty-six (21.7%) infections were due to MDR Gram-negative bacteria. ALT was used in 62 (29.2%) patients, with a 75.9% success rate. Risk factors identified for failure of the initial treatment were having a high sequential organ failure assessment (SOFA) score at diagnosis of infection and being in palliative care; introduction of ALT at the start of treatment was identified as a protective factor. Risk factors identified for 30-day mortality after LTCVC-associated infection were a high SOFA score at diagnosis, infection with MDR bacteria, and palliative care; introduction of ALT at the start of treatment, hematological malignancies, and adherence to an institutional protocol for the management of LTCVC-associated infection were identified as protective factors. Despite the high incidence of infection with MDR bacteria, ALT improves the outcome of LTCVC-associated infection in cancer patients.

Clinical Predictors of Port Infections in Adult Patients with Hematologic Malignancies

PURPOSE

To identify clinical predictors of port infections in adult patients with hematologic malignancies.

MATERIALS AND METHODS

A retrospective chart review identified 223 adult patients (age ≥ 18 y) with hematologic malignancies, including lymphoma (n = 163), leukemia (n = 49), and others (n = 11), who had a port placed from 2012 to 2015. Early (< 30 d after port placement) and overall port infections (bloodstream and site infections) were recorded. To elucidate clinical predictors for early and overall port infections, proportional subdistribution hazard regression (PSHREG) analyses were conducted with variables including patients' demographics, medications used, laboratory data, and port characteristics.

RESULTS

Total duration of follow-up was 83,722 catheter-days (median per patient, 274 catheter-days). Early and overall port infections were identified in 8 (3.6%) and 26 (11.7%) patients, respectively. Early and overall infection rates were 1.2 and 0.3 infections/1,000 catheter-days, respectively. Backward stepwise multivariate PSHREG analyses identified hypoalbuminemia (< 3.5 mg/dL) at the time of port placement (hazard ratio = 5.03; 95% confidence interval, 1.14-22.16; P = .03) and steroid use (> 30 d cumulatively during follow-up period) (hazard ratio = 3.41; 95% confidence interval, 1.55-7.47; P = .002) as independent risk factors for early and overall port infections, respectively.

CONCLUSIONS

In adult patients with hematologic malignancies, hypoalbuminemia at the time of port placement was a clinical predictor for early port infections, whereas steroid use was a clinical predictor for overall port infections.

CT-Guided Translumbar Placement of Permanent Catheters in the Inferior Vena Cava: Description of the Technique with Technical Success and Complications Data

PURPOSE

To evaluate indications, technical success rate and complications of CT-guided translumbar catheter placement in the inferior vena cava for long-term central venous access (Port and Hickman catheters) as a bail-out approach in patients with no alternative options for permanent central venous access.

MATERIALS AND METHODS

This retrospective study included 12 patients with a total of 17 interventions. All patients suffered from bilaterally chronically occluded venous vessels of their upper extremities, without patent internal jugular and/or subclavian veins. Catheter implantation was performed as a hybrid procedure with CT-guided translumbar access into the inferior vena cava with subsequent angiography-guided catheter placement of a Hickman-type catheter (7×) or a Port catheter (10×).

RESULTS

All interventions were technically successful. The total 30-day complication rate was 11.8% (n = 2). The two detected complications were bleeding at the subcutaneous port hub and subcutaneous kinking of the venous tube. Mean follow-up time was 68.4 ± 41.4 months (range 3.4-160 months). Six patients (50%) died during follow-up from non-procedure-related complications associated with the underlying disease. Late complications occurred in 8/17 (47.1%) cases and were infections of the catheter system in 35.3% (n = 6), mechanical defect of the catheter system in 5.8% (n = 1) and dislocation of the catheter system in 5.8% (n = 1). The overall infection rate was 0.77 per 1000 catheter days.

CONCLUSIONS

CT-guided translumbar placement of permanent catheters is a technically feasible and safe method for permanent central venous access as last resort in chronically occluded veins of the upper extremities.

Right or left? Side selection for a totally implantable vascular access device: a randomised observational study

BACKGROUND

Totally implantable vascular access device (TIVAD)-related complications interfere in the anticancer treatment and increase medical expenses. We examined whether the implantation side of central line TIVADs is associated with the occurrence of thrombotic or occlusion events.

METHODS

We enrolled patients with cancer who required central line TIVADs and randomised them to receive the TIVAD implantation on either the left or right side. The primary endpoint was the occurrence of catheter-related thrombotic or occlusion events.

RESULTS

We randomised 240 patients, of which 235 received TIVAD implantation according to the protocol. In the per-protocol cohort, 117 and 118 patients received implantation on the left and right sides, respectively. Catheter-related thrombotic or occlusion events occurred in 9 (4%) patients, accounting for 0.065 events per 1000 catheter-days. Between the patients with left- and right-sided implantations, the occurrence rates (P=0.333) and the time from catheter implantation to the occurrence of thrombotic or occlusion events (P=0.328) were both similar. In the multivariate analysis, the side of implantation remained unassociated with the occurrence of thrombotic or occlusion events.

CONCLUSIONS

The side of central line TIVAD implantation was not associated with the occurrence of catheter-related thrombotic or occlusion events in patients with cancer.

Vascular Access in the Pediatric Population

Vascular access procedures are an important and frequent component of the day-to-day practice of the pediatric surgeon. Most access procedures can be performed percutaneously via Seldinger or modified Seldinger technique and are aided by technology, such as ultrasound and fluoroscopy. Complications, such as infection, do occur, and the pediatric surgeon should be able to diagnose and treat these when they arise. The indications, techniques, and complications of vascular access are covered in this article.

Bloodstream infections in patients with solid tumors

Little information is currently available regarding bloodstream infection (BSI) in patients with solid tumors who, for a variety of reasons, are particularly predisposed to develop this condition. In this review we focus on the incidence, epidemiology, clinical features, etiology, antimicrobial resistance, and outcomes of BSI of adult cancer patients with solid tumors. Most episodes of BSI occur in non-neutropenic patients, in whom the site of primary or metastatic tumor often serves as the portal of entry. The urinary tract and the abdomen are the most frequent sources of infection, and cholangitis is the most common recurrent source of BSI. Gram-negative bacilli are becoming the leading cause of BSI in patients with solid tumors, and the rate of multidrug resistance is increasingly being recognized. The case-fatality rate in patients with solid tumors and BSI is high, especially among those with comorbidities, advanced neoplasms, corticosteroid therapy, and shock at presentation.

Incidence and risk factors for central venous access port-related infection in Chinese cancer patients

BACKGROUND/PURPOSE

Cytotoxic chemotherapy via central venous access ports is an important part of the standard treatment for most cancers, but it is accompanied with the risk of infections. This study aimed to analyze the incidence and risk factors for central venous access port-related infection (CPI) among Chinese patients receiving cytotoxic chemotherapy.

METHODS

Between January 1, 2002 and December 31, 2005 a total of 1391 cancer patients with 1449 totally implantable central venous access ports were evaluated. The log-rank test and Cox proportional hazards model were used for the analyses of risk factors.

RESULTS

The overall CPI incidence rate was 0.21 per 1000 catheter-days. Hematological malignancies and head and neck cancer were associated with an increased risk of CPI (hazard ratio 4.00 and 4.11, respectively, both p < 0.001) and less infection-free catheter longevity (p < 0.001) compared with other cancer types. Chemotherapy in an adjuvant setting was associated with a lower risk of infection than for patients in a nonadjuvant setting (p < 0.001). The most common pathogens isolated from CPI were Pseudomonas aeruginosa and Candida.

CONCLUSION

Infection remains to be a challenging issue for totally implantable central venous ports. Implementation of an insertion bundle for the prevention of central line-associated bloodstream infections is warranted, especially for those patients with hematological and head and neck cancers, as well as for patients receiving chemotherapy in the metastatic settings.

Long-term catheterization: current approaches in the diagnosis and treatment of port-related infections

Since the first description in 1982, totally implanted venous access ports have progressively improved patients' quality of life and medical assistance when a medical condition requires the use of long-term venous access. Currently, they are part of the standard medical care for oncohematologic patients. However, apart from mechanical and thrombotic complications, there are also complications associated with biofilm development inside the catheters. These biofilms increase the cost of medical assistance and extend hospitalization. The most frequently involved micro-organisms in these infections are gram-positive cocci. Many efforts have been made to understand biofilm formation within the lumen catheters, and to resolve catheter-related infection once it has been established. Apart from systemic antibiotic treatment, the use of local catheter treatment (ie, antibiotic lock technique) is widely employed. Many different antimicrobial options have been tested, with different outcomes, in clinical and in in vitro assays. The stability of antibiotic concentration in the lock solution once instilled inside the catheter lumen remains unresolved. To prevent infection, it is mandatory to perform hand hygiene before catheter insertion and manipulation, and to disinfect catheter hubs, connectors, and injection ports before accessing the catheter. At present, there are still unresolved questions regarding the best antimicrobial agent for catheter-related bloodstream infection treatment and the duration of concentration stability of the antibiotic solution within the lumen of the port.

Chlorhexidine for the prevention of bloodstream infection associated with totally implantable venous ports in patients with solid cancers

PURPOSE

To evaluate the preventive effects of topical skin disinfection with chlorhexidine on bloodstream infection (BSI) associated with totally implantable venous port (Port-A).

METHODS

Two consecutive cohorts of solid cancer patients were prospectively followed for the occurrence of Port-A associated BSI (PABSI). The first cohort used povidone-iodine as topical skin disinfection and the second cohort used chlorhexidine. The primary endpoint was the time to first PABSI. Propensity score analysis was applied. The preventive effects of chlorhexidine were analyzed by Cox proportional hazards models.

RESULTS

There were 396 patients (81,752 catheter-days) in the iodine cohort and 497 (99,977 catheter-days) in the chlorhexidine cohort. Gram-negative bacteria were the most common pathogens to cause first episode of PABSI (iodine cohort (I) vs chlorhexidine cohort (C) and 0.404 vs 0.450 per 1,000 catheter-day), followed by Gram-positive bacteria (I vs C and 0.269 vs 0.110 per 1,000 catheter-day), and fungi (I vs C and 0.098 vs 0.070 per 1,000 catheter-day). Three hundred forty-three patients were selected from each cohort by propensity score match analysis. Chlorhexidine use was associated with a significant improvement on time to first PABSI caused by Gram-positive bacteria (log-rank test, p=0.00175; HR=0.35, 95 % CI, 0.14-0.85, p=0.02). No significant preventive effects of chlorhexidine on time to first PABSI caused by Gram-negative bacteria or fungi was found.

CONCLUSIONS

Chlorhexidine topical skin disinfection may prevent PABSI caused by Gram-positive bacteria in patients with solid cancers. The nonsignificant effect on preventing overall PABSI may be attributed to the high incidence of Gram-negative bacteria related PABSI.